title: Symptomatic relapse of HIV-associated cryptococcal meningitis: recurrent cryptococcal meningitis or Cryptococcus-related immune reconstitution inflammatory syndrome?
abstract: Cryptococcosis, a significant opportunistic infection, has become a global concern since the advent of immunosuppressive chemotherapy or in immunodeficient patients. Host responses range from a harmless colonization to disseminated disease. An accurate or definitive diagnosis in patients with cryptococcal meningitis is often delayed because of the similar clinical presentation and biochemical or cerebrospinal fluid findings to those of a variety of infectious and non-infectious aetiologies, most of which are also especially prevalent in developing countries. Rarely, patients with cryptococcal meningitis can develop immune reconstitution inflammatory syndrome (IRIS) when initiated on combination antiretroviral therapy (cART) the diagnosis which is often missed and can be fatal. Due to the similar presentation of infection and IRIS, it is often confused with the relapse of cryptococcal meningitis. We report a case of paradoxical recurrent meningitis in response to the initiation of cART in a patient diagnosed with cryptococcal meningitis and propose that the recurrent symptoms resulted from a therapy-induced reconstitution of the immune response against residual Cryptococcus neoformans.
authors.affiliation: Department of Medicine, University College of Medical Sciences (UCMS) and Guru Teg Bahadur (GTB) Hospital, Delhi, India.
authors.forename: Rajat
authors.initials: R
authors.lastname: Jhamb
authors.forename: Bineeta
authors.initials: B
authors.lastname: Kashyap
authors.forename: Shukla
authors.initials: S
authors.lastname: Das
authors.forename: Neha
authors.initials: N
authors.lastname: Berry
authors.forename: Arun
authors.initials: A
authors.lastname: Garg
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000175:diagnosis / Q000188:drug therapy / Q000276:immunology; D000328:Adult; D019380:Anti-HIV Agents / Q000009:adverse effects / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use; D023241:Antiretroviral Therapy, Highly Active / Q000009:adverse effects*; D003455:Cryptococcus neoformans / Q000302:isolation & purification*; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy* / Q000276:immunology; D006801:Humans; D054019:Immune Reconstitution Inflammatory Syndrome / Q000139:chemically induced*; D008297:Male; D016919:Meningitis, Cryptococcal / Q000175:diagnosis* / Q000188:drug therapy / Q000276:immunology; D012008:Recurrence; D016896:Treatment Outcome
chemical_list: D019380:Anti-HIV Agents; D000935:Antifungal Agents
keywords: AIDS; Cryptococcal meningitis; Cryptococcus neoformans; HIV; IRIS; antiretroviral therapy; diagnosis; immune reconstitution inflammatory syndrome; recurrent